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3 <br /> Orange County <br /> • Agricultural Districts Advisory Board <br /> APPLICATION FOR CERT1riCATION AS QUALIFYING FARMLAND <br /> AND DESIGNATION AS AN ORANGE COUNTY <br /> VOLUNTARY AGRICULTURAL DISTRICT <br /> INSTRUCTIONS: Before completing the application, please review the provisions of the Orange County Voluntary Farmland <br /> Preservation Program Ordinance, then fill out the form as accurately and completely as possible. Be sure to <br /> sign and date the form, and return it to the Orange County Planning &Inspections Department, 306F Revere <br /> Road, Hillsborough, N.C. <br /> APPLICANT: <br /> Name: �A F li") j Wyk. N/ <br /> Address: sso c- M r, u n-(- v, C r - • <br /> City:Ciia p¢ ( I I State: C ZIP Code: eg 7 S <br /> • Phone Number:(Home) i(c '7 - 3 o '7 (Work) Li -7 1 —LS3 1 <br /> PROPERTY INFORMATION: <br /> Property Location/Address: 57) h't n(.4 r -`-ct„ \ dv-. U • <br /> Township:Cjna F ( 141 I I Tax Map: Block: Lot: <br /> Parcel Identification Number [PIN): Sew <br /> a.Tra-��rn en7L <br /> Number of Acres: J'76, ,'7 Deed Book: Page: / <br /> Does this land have a plan on file with the Soil Conservation Service or U.S. Forest Service? <br /> Yes: No: If "no", please complete back of form. <br /> Is this land listed fcr farm present use-value taxation with the Orange County Tax Office? <br /> Yes: V No: If "no", please complete back of form. <br /> OWNER[S] CERTIFICATION: <br /> I [We], the applicant[s], hereby certify that, to the best of my [our] ability, the foregoing <br /> application is complete and accurate. <br /> Signature: Date: <br /> - _ <br /> Signature: .J, _ 4J _ Date: 0( 63 3 <br /> Please direct inquiries to: <br /> Orange Soil&Water Conservation District <br /> Cooperative Extension Service <br /> Orange County Planning &Inspections Department <br /> Hillsborough 732-t1El'Cl ipel Hill 967-9231 Durham 6111-7031,Winos 227-A3l <br />